TRICARE Supplemental Insurance Plan | Benefits

Available to TRICARE Beneficiaries, regardless of Rank, Service or Duty Status

How the TRICARE Supplement Plan works to pay after TRICARE Standard/Extra Pays

Care Required TRICARE Standard/Extra Pays Your TRICARE Standard/Extra Supplement High Option II Plan Pays
Inpatient confinement in civilian hospitals for RETIREES and dependent family members (room, board, supplies and staff services billed by the hospital) The TRICARE Standard/DRG amount (contracted rate for TRICARE Extra)minus your cost share. The lesser of $535/day or 25% of billed amount, not to exceed the TRICARE Standard DRG amount (lesser of $250/day or 25% cost share of the contracted rate for TRICARE Extra) AFTER you satisfy the fiscal year plan deductible PLUS 100% of covered excess charges up to the Legal Limit.)
Inpatient confinement in civilian hospitals for RETIREES and dependent family members (doctors, and other inpatient services not billed by the hospital) 75% of the TRICARE Standard allowed amount (80% for TRICARE Extra) for doctors and other professional services. Your cost share AFTER you satisfy the **fiscal year plan deductible PLUS 100% of covered excess charges up to the Legal Limit.
Inpatient confinement in military hospitals. All but the daily subsistence fee. The daily subsistence fee.
Outpatient care for RETIREES and dependent family members (office visits, clinics, lab, prescription drugs, etc.) 75% of the TRICARE Standard allowed amount (80% for TRICARE Extra)after you pay the TRICARE Outpatient Deductible. Your cost share AFTER you satisfy the fiscal year plan deductible PLUS 100% of covered excess charges up to the Legal Limit. For prescription drugs - the plan pays your copayment amounts.
Inpatient confinement in civilian hospitals for ACTIVE DUTY dependents

Outpatient care for ACTIVE DUTY dependents (office visits, clinics, labs, prescription drugs, etc.)
All allowable charges except daily subsistence fee or $25, whichever is greater.

80% of the TRICARE Standard allowed amount (85% for TRICARE Extra) after you pay the TRICARE Outpatient Deductible.
Active Duty Plan - $25 or the daily subsistence fee, whichever is greater.

Active Duty Plan - Your cost share PLUS 100% of covered excess charges up to the reasonable and customary community standard level, AFTER you pay the Tricare Extra/Standard Outpatient Deductible.*

**Legal Limit means the maximum amount that a non-participating provider can legally charge. This amount is up to the 115% of the TRICARE Allowed Amount.

  • Eligibility
  • Termination
  • Exclusions
  • Effective Date
  • Limitations
  • FAQ's

Eligibility - TRICARE SUPPLEMENT

You are eligible to enroll if you are a TRICARE eligible recipient, under age 65, and entitled to retired (Military), retainer, or equivalent pay. If you are age 65 or over and ineligible for Medicare, you may apply for the plan by attaching a copy of your Social Security Notice of Disallowance of Benefits to your Enrollment Form. If you are:

  • Retirees of the uniformed services, their spouse and unmarried dependent children (under age 21 or 23 if a full-time student)
  • Spouse or surviving spouse of retired military personnel and dependent children under age 21 or 23 if a full-time student.
  • Retired Reservists and National Guard members (gray area retirees) under age 60 and enrolled in TRICARE Retired Reserve (TRR)
  • Spouse and unmarried eligible dependent children (under age 21 or 23 if a full-time student) who are eligible for CHAMPVA

Termination

Your coverage under the Policy will cease on the first to occur of:

  1. The date the Policy terminates;
  2. The date the required premium is not paid, subject to the Grace Period provision;
  3. The first day of the month on or next following the date you cease to be a member of the Policyholder;
  4. The first day of the month on or next following the date you cease to be eligible for the Plan under which you are covered;
  5. The date we or the Policyholder cancel coverage for a Class of Eligible Person to which you belong;
  6. The date you attain age 65;
  7. The date you cease to be covered under TRICARE;
  8. The date you become eligible for Medicare unless you reside in an area where Medicare is not available, in which case coverage will not terminate until you return to residency in an area where Medicare is available. Termination of coverage will be without prejudice to any claim which originated before the effective date of termination.

Exclusions

The Policy does not cover:

  1. Injury or sickness resulting from war or act of war, whether war is declared or undeclared
  2. Intentionally self inflicted injury
  3. Suicide or attempted suicide, whether sane or insane (in Colorado and Missouri, while sane)
  4. the following services: a) routine physical exams, unless required for school enrollment (but not sports physicals) by a Covered Child aged 5 through 11; and b) immunizations; except that these services are covered when rendered to a Covered Child who is less than 6 years of age
  5. Domiciliary or custodial care
  6. Eye refractions and routine eye exams except when rendered to a child up to 6 years from his or her birth
  7. Eyeglasses and contact lenses
  8. Prosthetic devices, (except that artificial limbs and eyes and devices which must be implanted by surgery are covered)
  9. Cosmetic procedures, except those resulting from Sickness or Injury while a Covered Person
  10. Hearing aids
  11. Orthopedic footwear
  12. care for the mentally incapacitated or physically handicapped if the care is required because of the mental incapacitation or physical handicap or the care is received by an Active Duty Member’s child who is covered by the "Program for the Handicapped" under TRICARE
  13. drugs which do not require a prescription, except insulin
  14. Dental care unless such care is covered by TRICARE, and then only to the extent that TRICARE covers such care
  15. Any confinement, service, or supply that is not covered under TRICARE
  16. Hospital nursery charges for a well newborn, except as specifically provided under TRICARE
  17. any routine newborn care except Well Baby Care, as defined, for a child up to 6 years from his or her birth
  18. TRICARE eligible cost-share and deductible amounts in excess of the TRICARE Cap
  19. Expenses which are paid in full by TRICARE
  20. Any expense or portion thereof applied to the TRICARE Outpatient Deductible
  21. Treatment for the prevention or cure of alcoholism or drug addiction except as specifically provided under TRICARE
  22. Any part of a covered expense which the Covered Person is not legally obligated to pay because of payment by a TRICARE alternative program
  23. And any claim under more than one of the TRICARE Supplement Plans, or under more than one Inpatient Benefit or more than one Outpatient Benefit of the TRICARE Supplement Plans. If a claim is payable under more than one of the stated Plans or Benefits, payment will only be made under the one that provides the highest coverage, subject to the Pre Existing Condition Limitation.

Effective Date

Your coverage and that of your covered dependents becomes effec­tive on the first day of the month following receipt of your enrollment form and first premium payment. If, on that day, you or a covered dependent are confined in a hospital, the effective date will be the day following discharge from the hospital.

Deferred Effective Date: If on the date that You are to become covered under the Policy you are confined in a Hospital, your coverage will be deferred until the first day after You are discharged.

Deferred Effective Date (Dependent): If on the date that an Eli­gible Dependent is to become covered under the Policy he or she is confined at home, in a Hospital or elsewhere because of injury or sick­ness, coverage of such person will be deferred until the first day after he or she is discharged from the Hospital or place of confinement.

Limitations

Newborn children not named in your enrollment form are automatically covered from birth for injury or sickness, including treatment of congenital defects and birth abnormalities, for 31 days. You must notify the Plan Administrator in writing and pay the additional premium due within 31 days of birth for coverage to continue beyond this period. Insured children who are incapable of self-sustaining employment because of mental retardation or physical disability- and who are unmarried and chiefly dependent on the insured member for support and maintenance—may continue coverage past policy age limits, with a dependent.

Rates are based on the attained age of the insured person and increases as you enter each new category. Rates and /or benefits may be changed based on a class basis.

Pre-Existing Conditions Limitation

Any injury or sickness whether diagnosed or undiagnosed, for which a covered person received medical care or treatment within the 6 month period preceding the effective date of his or her insurance will not be covered until the coverage has been in effect for 6 months. However, new conditions will be covered immediately.

The Pre-existing condition limitation may be waived under the following conditions:

For individuals who are newly retired from active duty military and who enroll in the plan within 63 days of the military retirement date. Application for coverage should include a copy of their DD-214.

For individuals who were previously enrolled in a non-TRICARE Supplement Employer Group Plan and loses that coverage due to involuntary termination. Such individuals must enroll in the Supplement Plan within 31 days following the termination date of the prior insurance plan. Application for coverage under the Supplement Plan should include a copy of the Certificate of Creditable Coverage for the prior group insurance plan.

TRICARE Supplemental Insurance | FAQ's

Q1.

Is there a maximum limit on benefits (lifetime, annual, etc.)?

 

When the TRICARE cap of $3,000 is met, TRICARE will pay 100% of covered medical expenses. The supplement pays nothing. However, the supplement will pay 100% of covered excess charges over the cap. Additionally, Inpatient treatment for mental, nervous or emotional disorders in excess of 45 days if under age 19, or 30 days if age 19 or older, is limited to 90 days (if approved by TRICARE)in a calendar year. Outpatient benefits for mental, nervous or emotional disorders, drug addiction or alcoholism are limited to a maximum of $500 in a 12 month period.

   
Q2. Will the plan cover amounts beyond what TRICARE allows?
  The Plan will pay 100% of covered excess charges up to the legal limit.
   
Q3. Does the plan pay for services that aren’t covered by TRICARE?
  No.
   

Q4.

Will the plan pay the TRICARE outpatient deductible?

  The High Option II plan has a fiscal year Plan deductible of $250 per person and $500 family maximum.
   

Q5.

How will the plan require premium payments?

  Premiums may be paid monthly by deduction from checking account (Check-o-Matic) or direct bill - quarterly, semi-annually or annually. Credit cards may not be used to pay premiums.
   

Q6.

What happens when I reach age 65?

  At age 65, eligibility under the TRICARE Supplement or CHAMPVA Supplement ends for members and their spouses. Coverage may be continued under the Supplement Plan if you are ineligible for Medicare or reside overseas. If ineligible for Medicare, you must submit a copy of your Social Security Disallowance Notice to ASI in order for coverage to be continued.

If at age 65, you are eligible for Medicare Part A and enrolled in Medicare Part B your TRICARE or CHAMPVA eligibility will continue. Medicare will be your primary carrier and you will have supplemental coverage under TRICARE for Life (or CHAMPVA for Life if you are a CHAMPVA beneficiary).
   

Q7.

Does the plan convert to a Medicare Supplement? If so, must it be in force as a TRICARE supplement for any specified length of time before conversion?

  No, the plan does not convert to a Medicare Supplement Plan. At age 65, TRICARE FOR LIFE kicks in and benefits are paid between TRICARE and Medicare (providing the individual has Part B of Medicare.)
   

Q8.

Will the plan cover you overseas?

  Yes. TRICARE coverage is worldwide. If TRICARE pays for covered medical expenses overseas, the plan will pay its contractual benefit.
   

Q9.

Can premium payments be increased? Under what conditions?

  Premiums increase as a person moves from one 5-year age bracket to another (40, 45, 50, 55, 60). The company reserves the right to change premiums on a group wide basis to maintain the financial solvency of the plan.
   

Q10.

What are the membership fees (annual, lifetime, etc.), if any, when you join the organization that sponsors the plan?

  GEA $24 annual membership fees.
   

Q11.

Does the plan cover the service member when he/she retires?

  Yes. If the member enrolls within 63 days from the time he/she retires from the military, providing his dependents had already enrolled in our TRICARE Supplement Plan, the retiree will not be subject to the Pre-Existing Condition provision. If the retiree waits beyond the 63 day period, he/she is subject to the Pre-Existing Condition clause.
   

Q12.

If you’re retired military and have a health care plan (which pays before TRICARE) through a civilian job, do you still need a TRICARE supplement if, between them, your employer’s plan and the TRICARE health care option you’ve chosen will pay most or all of your civilian medical bills?

  No.
   

Q13.

How are claims filed with the Supplement?

  All claims are filed first with TRICARE or CHAMPVA. After TRICARE/CHAMPVA has processed your claim, they will send you an Explanation of Benefit Statement (EOB). You will need to file a claim with the Supplement Plan only if the provider has not agreed to file one on your behalf. To file a supplement claim, simply write your certificate (member ID) number on the EOB and also, write "Pay Provider" if you would like the benefits paid directly to the provider, otherwise the benefits will be paid to you. According to TRICARE, 98% of providers submit claims directly to TRICARE. Most providers will also submit claims directly to ASI for the Supplemental coverage. You should always ask your provider to file your supplemental claim for you.

Claims may be mailed to: ASI, P.O. Box 2510, Rockville, MD 20847
   

Q14.

How are prescription drugs covered under the Supplement?

  When you visit a pharmacy, show your military ID card (or CHAMPVA ID card if you are a CHAMPVA beneficiary) and pay the copayment (cost share) amount. Your prescription drug co-pay receipt (showing the name of the drug, date filled, and copayment (cost share) amount) should be submitted to Association & Society Insurance Corporation (ASI) for reimbursement.
   

Q15.

Up to what age are dependents eligible?

  For TRICARE, unmarried dependent children are eligible up to age 21, and up to age 23 if a full-time student. For CHAMPVA, unmarried dependent children are eligible up to age 18, and up to age 23 if a full-time student.
   

Q16.

Are incapacitated dependents eligible for coverage?

  If an incapacitated unmarried child who is covered under the policy reaches age 21 or 23, his/her coverage will not terminate due to age if he/she continues TRICARE eligibility due to the incapacity. Coverage will continue as long as the unmarried child qualifies as an incapacitated child and the required premium is paid.
   

Q17.

How does the TRICARE Extra/Standard Supplement Plan coordinate with TRICARE?

  Unless also enrolled under another Group Insurance Plan, TRICARE is the primary payer and the Supplement Plan is secondary. Thus, you are able to take full advantage of your military benefits. Your claims are filed first with TRICARE, then the TRICARE Explanation of Benefit (EOB) Statement is sent to the Supplement Plan. The Supplement Plan will pay for your TRICARE cost share, (TRICARE Standard deductible if enrolled in the Comprehensive Plan option) and covered excess charges after you meet the Supplement Plan deductible.
   

Q18.

Under what circumstance would a member, age 65 or older, be eligible for the TRICARE Supplement?

 

There are two circumstances that would allow continuing eligibilty for members who are 65 or older:

  1. The TRICARE beneficiaries who live/work out of the United States of America. They must be eligible for Medicare Part A and enrolled in Medicare Part B, and TRICARE must have the information on file with the Defense Enrollment Eligibility Reporting Systems (DEERS).
    You may contact DEERS at:
  2. 1-800-538-9552  (in the continental United States)
    Fax address changes to: 1-831-655-8317
  3. Write to: DEERS Support Office, 400 Gigling Road, Seaside, CA 93955-6771
  4. Beneficiaries who are ineligible for Medicare. These members must have received a Statement of Disallowance from Social Security Administration.

TRICARE SUPPLEMENTAL INSURANCE

IMPORTANT NOTICE:


The Plan is currently not available in CO, ME, NH, NV, OR, WA.